**2. Carotid endarterectomy**

Carotid endarterectomy (CEA) started in the early 1950s and is now the most commonly performed peripheral arterial surgery in the USA. The aim of CEA is to remove the entire atherosclerotic plaque from the carotid bifurcation en bloc leaving a rough surface to be endothelialized over the following weeks. Most procedures are performed under general anesthesia. However, local anesthesia and mild intravenous sedation are sometimes successful and can allow monitoring of neurologic functions during surgery. Local anesthesia also should

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be considered in the hemodynamically unstable patient or in situations where general anesthesia may be too risky.

### **3. The early years of carotid endarterectomy**

Early attempts at reconstruction of the carotid artery at the bifurcation were carried out by Carrea, Molins, and Murphy in 1951 and subsequently by Eastcott, Pickering, and Robb in 1954. In 1965 DeBakey reported that he performed the first CEA in 1953. Although not published, there is controversy about this claim.[1] Subsequently, a group of neurologists, vascular surgeons, and neurological surgeons performed a study on the "new technique" comparing it with medical therapy. Interestingly, the surgical mortality was surgical mortality of 4.5% in 2400 operations. This early study the study delineated careful methods of measuring common carotid and internal carotid and vertebral artery stenosis. The study also determined the upper level of ready surgical accessibility as well as the contraindications to the operation. [2] Additionally, myocardial infarction was identified as the principal cause of late mortality in those patients undergoing successful surgical treatment. Providing the patients survived the surgical therapy, the occurrence of new stroke was 4% in the surgical group. However, the superiority of surgery over medical therapy was not definitive. Despite criticism, CEA became extremely popular. It became the most commonly performed peripheral arterial procedure in the United States, reaching a peak of 107,000 operations in nonveteran hospitals in the United States in 1985.[1] At that time, however, neurologists were skeptical. Their fears were sup‐ ported by reports that the rates of death or stroke from CEA were 10%. Endarterectomy turned from a great procedure to an operation "that has escaped critical analysis to be let loose on an unsuspecting public"![3] These concerns stressed the need to perform well-designed random‐ ized trials under independent neurological audit. Those trials established the role of CEA versus medical treatment for stroke prevention.
